MEDICARE: MRS. MARTHA SIMMS MIKELL MSED, ATC, CSCS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	0126000100	VA

General Provider Information

NPI Number	:	1336179290
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARTHA SIMMS MIKELL MSED, ATC, CSCS

Provider Business Mailing Address
First Line	:	45 FLORY AVE
Second Line	:
City	:	STUARTS DRAFT
State	:	VA
Zip	:	24477-2944
Country	:	US
Telephone Number	:	540-337-2638
Fax Number	:

Provider Business Practice Location Address
First Line	:	1028 AUGUSTA FARMS RD
Second Line	:
City	:	STUARTS DRAFT
State	:	VA
Zip	:	24477-3200
Country	:	US
Telephone Number	:	540-886-8500
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/04/2006
Last Update Date	:	07/08/2007

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